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CDC Telebriefing Transcript
New CDC Treatment Guidelines Critical to Preventing Health Consequences of STDs
May 9, 2002
CDC MODERATOR: Good afternoon all. Our topic for today's call is going to be the 2002 STD Treatment Guidelines. Joining us today is Stuart
Berman, M.D., and his name is spelled S-t-u-a-r-t B-e-r-m-a-n. He is the Chief of the Epidemiology and Surveillance Branch in CDC's Division of
STD Prevention.
With him today is Kimberly Workowski, M.D. Her name is spelled W-o-r-k-o-w-s-k-i. She is the lead author of today's guidelines.
Susan Wang, M.D. also joins us. Her last name is spelled W-a-n-g. She is an expert in drug resistant gonorrhea.
We also have with us today Dr. Ann Duerr, a reproductive health expert. Her last name is spelled D-u-e-r-r.
After a few remarks, all of our speakers are going to be available to answer your questions. I am now going to turn the call over to Dr. Stuart
Berman.
DR. BERMAN: Thank you very much, Cynthia.
And good afternoon to all of you who have joined us today. You should have received a fact sheet on the guidelines by now. If you haven't, it's
available at www.cdc.gov/std/media. That's m-e-d-i-a. Or you can get it by calling our Office of Communication at 404-639-8895.
Today I'll give you a brief overview of the 2002 Guidelines for the Treatment of Sexually Transmitted Diseases and review some of the most
notable recommendations that are in your guidelines, and then we'll open up the call to some questions.
These 2002 Guidelines for the Treatment of Sexually Transmitted Diseases are designed to advise health care providers on the most effective
treatment regimens and screening procedures and prevention strategies to address STDs. CDC revises these guidelines about every 4 years using a
scientific evidence based review process. This is the fifth CDC edition of these guidelines.
Now, let me begin with highlighting some of the changes that are in our screening recommendations. Screening for chlamydia is very important,
since otherwise cases go unrecognized and can silently cause pelvic inflammatory disease which can damage a woman's fallopian tubes, uterus and
ovaries, and impair fertility.
In keeping with other recommendations that have been previously published, sexually active adolescent females, 19 years of age and younger, and
all adult and young adults within 20 to 24 years of age, should be screened annually even if they don't have symptoms. Older women with a risk
factor for chlamydia, such as having a new sex partner or multiple sexual partners, these women should also be screened annually.
What's new is that we are now advising health care providers to rescreen all woman who are diagnosed with chlamydia about 3 or 4 months after
these women complete initial treatment. This new guidance on rescreening was issued as a result of the high prevalence of chlamydia that's been
found in women who were previously diagnosed with the disease and treated several months before that.
Next topic I would want to sort of highlight in terms of the high points in our guidelines is that due to increased rates of syphilis and
gonorrhea that has been found among men who have sex with men in many United States cities, these new guidelines include detailed
recommendations for expanded screening in this high-risk population. First, providers recommend a need to assess the gender of the partners that
these male patients, that their male patients have, and for their gay and bisexual patients, health care providers are urged to screen annually
for chlamydia, syphilis and gonorrhea. These patients should also be screened for HIV if they are uninfected or if their HIV status is unknown.
Providers also should encourage their patients to be vaccinated against hepatitis-B and hepatitis-A. More frequent screening than mentioned
above, than really annually, may be necessary for those patients who have had multiple anonymous partners or those who have had sex in
conjunction with illicit drug use.
Next, I'd like to address an issue that's relevant for the millions of people who are infected with genital herpes. And for these people, CDC is
advising providers that there are new serologic tests that are available that can help with the diagnosis and management of genital herpes.
These tests could help providers if a patient is infected with herpes simplex type 1 or herpes simplex type 2. The majority of individuals with
recurring genital outbreaks are infected with herpes type 2 and may benefit from either suppressive antiviral treatment which can prevent future
outbreaks, or episodic treatment which can shorten the duration of the outbreaks when they occur.
Now, with that, I'd like to now discuss what we think is the most notable change to CDC's STD Treatment Guidelines. And this is that now we
think it's inadvisable for providers in California to use fluoroquinolone antibiotics for the treatment of gonorrhea because resistance to that
class of drugs by gonorrhea has become unacceptably common in that state. Now, fluoroquinolones include ofloxacin, levofloxacin and
ciprofloxacin. Now, this is the first time CDC has issued this guidance for the continental United States. Previously, CDC had recommended that
providers not prescribe fluoroquinolones for treating gonorrhea in Hawaii and those patients who visited that state, visited other Pacific
Islands or Asia, because a substantial proportion of gonorrhea cases in those areas have been found to be resistant to ciprofloxacin.
For treatment of gonorrhea in Hawaii and California, CDC now recommends providers us the antibiotics cefixime, which is given orally, or
ceftriaxone, which is administered by injection.
CDC made these changes and recommendations after examining data from the Gonococcal Isolate Surveillance Project or GISP as it's called, a CDC
sponsored surveillance system which monitors drug resistance of gonorrhea. 26 STD clinics participate in GISP by collecting gonorrhea cultures
and submitting them to one of 5 regional GISP laboratories for antimicrobial susceptibility testing. Since GISP is limited to just several areas
in the United States, CDC advises state and local public health officials to maintain a capacity to detect and monitor the prevalence of
drug-resistant strains of gonorrhea since prevalence can vary greatly by location.
Data from local drug susceptibility testing are needed to guide local treatment recommendations. Providers across the country should take a
travel history from their patients with gonorrhea to ensure that they are not infected in areas--that didn't become infected in areas where drug
resistance is prevalent. Cefixime or ceftriaxone should be prescribed for those patients who may have been infected in California, Hawaii, the
Pacific Islands or Asia.
Next CDC has updated these guidelines to reflect previous recommendations that had been made in the year 2000 and 2001 concerning the use of the
nonoxynol-9. Spermicides containing nonoxynol-9 should not be used alone since studies in Africa found that N-9, as it's called, can cause
vaginal lesions and may increase the risk of HIV transmission. N-9 lubricants should not be used during anal intercourse because studies have
shown that N-9 causes damage to the lining of the rectum, providing an entry point for HIV and other STD's.
While the level of N-9 used as a lubricant in condoms is much lower than the level found to be harmful, lubricants--condoms lubricated with N-9
spermicide are also not recommended because they have a shorter shelf life, cost more, and have been associated with urinary tract infections in
women. However, previously purchased condoms that had N-9 can be used provided they haven't passed their expiration date. Condoms lubricated
with N-9 are not suggested, but undoubtedly the use of N-9 lubricated condoms is safer than not using any condom at all.
Finally, the clinical prevention guideline section in the treatment guidelines has also been revised for 2002 and providers are now advised to
focus on risk assessment and counseling of their patients in addition to the clinical aspects of STD control. With that, we'd like to begin
taking any questions you might have.
AT&T MODERATOR: Ladies and gentlemen, if you wish to ask a question, please press the 1 on your touchtone phone and you will a tone
indicating that you are in queue. You may remove yourself from queue at any time by pressing the pound key. If you're using a speaker phone,
please pick up your handset before pressing the number.
Our first question comes from Charlie Ohrenstein (ph) with the LA Times. Please go ahead, sir.
QUESTION: Hi there. I have a question in terms of the last time you made a recommendation or when you recommended that penicillin not be used to
treat gonorrhea, and then also for tetracycline and doxycycline.
CDC MODERATOR: Charlie, can you repeat that question again?
QUESTION: Sure. When did you issue a recommendation for penicillin not to be used to treat gonorrhea, and similarly, when did you issue the
recommendation for tetracycline and doxycycline in the past?
DR. WANG: This is Susan Wang. CDC recommended in 1987 that penicillin should no longer be used for treatment of gonorrhea, and in 1985 CDC
recommended to no longer use tetracycline for the treatment of gonorrhea.
QUESTION: And since 1987 you haven't made any recommendations with regard to not using any particular antibiotic?
DR. WANG: That's correct.
AT&T MODERATOR: Next question.
DR. WANG: I'm sorry, one other thing. In 2000 we did make specific recommendations for the State of Hawaii, that if a patient had acquired
gonorrhea infection in the State of Hawaii or Asia or the Pacific Islands, that they should not be treated with fluoroquinolones, and we also
said that if clinicians on the mainland U.S., if they elicited travel history that the patient may have acquired their gonorrhea in Hawaii or
Asia, et cetera, they should also not treat their patients with fluoroquinolones. So September 2000 we made that recommendation.
QUESTION: Thanks.
CDC MODERATOR: Next question.
AT&T MODERATOR: Our next question comes from Christopher Heradia (ph) with the San Francisco Chronicle. Please go ahead, sir.
QUESTION: Hi. You mention in your report that female adolescents are physiologically more susceptible to a chlamydia infection. I'm wondering
why that is, and also a question about primary care physicians asking their patients about the gender of their sexual partners. Is that--you
know, how do you address the pitfalls with that with the people who don't acknowledge that they're--you know, that they're engaging in
homosexual behavior? You've probably heard of, you know, on the down-low and stuff like that.
DR. WORKOWSKI: Correct. This is Dr. Workowski. Let me address the first question you had about adolescents. There are--what we say, there are
physiological reasons which puts an adolescent at risk, and what that basically means are anatomic reasons. The cervix, which is the opening of
the uterus, is lined by a specific type of cell, squamous epithelial cells. The inside of the cervix, the cervical OS, which is the opening from
the cervix into the uterus, is lined by a different type of cell called columnar epithelial cells. And what happens is in adolescents, they have
a very exuberant amount of columnar epithelial cells which extrude out through the opening of the cervix, and these are the exact cell types
that chlamydia infects, and as one gets older these cells tend to regress and go in through the OS, and so you really don't have much of this
extrusion of these columnar epithelial cells.
So this is just a manifestation of age, and that younger adolescents have more surface area of the columnar epithelial cells that are available
for chlamydia to infect. And since chlamydia tends to be in the section that is relatively asymptomatic in females, it's particularly important
for females, for anatomical reasons because of these changes I mentioned in the cell types as well as the asymptomatic nature of the infection,
the need to screen annually.
Does that answer your first question?
QUESTION: Yes. How do you spell columnar epithelial?
DR. WORKOWSKI: Columnar, c-o-l-u-m-n-a-r.
And your second question had to do with sexual orientation. And as a provider myself, I'm very keenly aware of the necessity to ask important
questions, just as it's important to ask your patient about using alcohol, tobacco, wearing seatbelts and other health-related activities, it's
important to know in terms of for the sexual health of your patient to inquire about their sexual orientation. And it's important for you to
provide educational messages. What's important in terms of safe sex behavior, the importance of abstinence, monogamy, as well as the importance
of using protection for--with new sexual partners.
And the difficulty that comes up is a lot of times providers have reticence in asking these questions to their patients, and one of the ways I
found helpful to broach the subject with patients is to ask whether they have sexual relations with men, women or both, which is a
non-judgmental way of asking the question, and it opens the floor up for patients to talk about sexual orientation, and then just continue to
have open-ended questions with the patient, which is extremely important, not yes or no answers, but an open-ended question where you can get a
patient to talk in an open-ended dialog.
CDC MODERATOR: The next question, please.
AT&T MODERATOR: Our next question comes from Aaron McClan (ph) with Associated Press. Please go ahead.
QUESTION: Hi, a couple of things. First of all, if Dr. Workowski could spell her first name, I'd appreciate that.
DR. WORKOWSKI: K-i-m-b-e-r-l-y.
QUESTION: Okay, thank you. On these recommendations for screening among gay and bisexual men, if you could spell out exactly what the
recommendation was before in terms of who needed to screened and how often. And also, it seems like this is in line with what we've been hearing
for several years about the concern that this unprotected sex and higher syphilis and gonorrhea rates are going to lead to a new spike in HIV
infections and AIDS cases?
DR. BERMAN: Yes. Thank you for the question. Stuart Berman. You know, you're right that there has been increased awareness of the level of risk
behavior among men who have sex with men, and one of the points that this guidelines and even this press briefing should address is greater
awareness among providers about the risk behavior of their patients and greater awareness among MSM themselves about the risk that they put
themselves and their partners at with behavior such as that, and that use of condoms is effective.
But in terms of the guidelines, the recommendations before, there really haven't been recommendations before that we have had out, or other, I
think, you know, [inaudible]. And this is reflecting growing awareness of the need for these recommendations and input from our expert advisers.
CDC MODERATOR: Aaron, is that it?
QUESTION: That's it, thank you.
CDC MODERATOR: Okay, next question.
AT&T MODERATOR: Our next question comes from Paula Moyer with Reuters Health. Please go ahead.
QUESTION: Greetings. I'm writing for physician readers and I would just like to, in a nutshell, hear from any of you what providers should be
telling their patients about the new guidelines and what--and what the providers themselves should know about the guidelines?
DR. WORKOWSKI: This is Dr. Workowski. I think the importance for providers is to let them know that these guidelines exist, and they exist as a
source of guidance for themselves as well as for patients to become knowledgeable in the detection and management of sexually transmitted
diseases.
In the press release you've gotten, you've gotten some of the major points that we think are the most important both for providers and for
patients. There are a number of other issues throughout--you know, this is a very big document. And I can't talk about all of the nuances of all
of the changes and things, and we highlighted what we thought was most important. Are there any questions you have in particular about certain
areas?
QUESTION: Well, one of the things I wondered, back to the nonoxynol-9 treated condoms, are they--are they to be avoided at all, or what should
people be doing with them?
DR. WORKOWSKI: Well, the exact language that we talk about in the guidelines, something that providers should know, is that condoms lubricated
with these N-9 spermicides are no more effective than lubricated condoms in protecting against the transmission of HIV and other STDs. What we
will say is that distribution of previously purchased condoms lubricated with N-9 should continue provided the condoms have not passed their
expiration date. However, the purchase of any additional condoms lubricated with N-9 is not recommended because these condoms cost more, they
have a shorter half life, and they have been associated with urinary tract infections in young women.
And I would probably ask Dr. Duerr if she had any additional comments from the N-9 MMWR that's coming out.
CDC MODERATOR: Dr. Duerr's a reproductive health expert and can look at is from the--
QUESTION: Okay. That sounds great. I've got a call into her.
CDC MODERATOR: Ann, do you want to go ahead and answer that now?
DR. DUERR: Yes. I think we would concur with exactly what you said about N-9 lubricated condoms. In addition, we, from the reproductive health
side, we would just like to add the point that there are contraceptives that contain nonoxynol-9, and for women who are not at risk for sexually
transmitted diseases, for HIV, these are a perfectly acceptable and safe contraceptive.
QUESTION: Okay, thank you.
CDC MODERATOR: Next question, please.
AT&T MODERATOR: Our next question comes from Richard Knox with National Public Radio. Please go ahead.
QUESTION: Yes, hi. To extend a little bit on that N-9 issue, it's clear what your advice is, I think, on N-9 lubricated condoms, but what's not
clear to me is what the implications are for the women who use diaphragms, and as your statement for the press release pointed out, diaphragm
use for contraception is only approved in conjunction with using spermicides, spermicide-containing gels and foams. So what should women who
rely on diaphragms and their clinicians be taking away from these recommendations concerning the safety of N-9 for them, presumably at the
higher dose in those formulations.
DR. DUERR: This is Dr. Duerr, and I think I'll take that question. You are correct that the current labeling for a diaphragm indicates that they
should be used with a spermicidal product, a cream or a jelly. And women who wish to use a diaphragm should be advised that the use of the
diaphragm or the N-9 containing spermicides do not protect against HIV or STDs. Women at risk of HIV and STDs should be advised that they should
use condoms consistently and correctly for protection against HIV and STDs, regardless of whether or not they're using other contraceptive
products.
However, as I stated earlier, women who are not at risk for HIV and STDs can safely use a diaphragm with the jelly or creams that contain
nonoxynol-9 for contraceptive purposes.
QUESTION: Is there an increased risk of urinary tract infections with the use of these foams and jellies containing N-9 and the diaphragm?
DR. DUERR: That has been reported. I would just also like to add one point, which is that there are ongoing trials currently of the use of a
diaphragm with spermicidal products which do not contain nonoxynol-9, and if these products are effective, they would increase the options for
women who choose to use a diaphragm for contraception.
QUESTION: Are these in Phase III? Excuse me.
DR. DUERR: These are in Phase III. Yes, it is, in Phase III trial.
QUESTION: Thank you.
CDC MODERATOR: Next question, please.
AT&T MODERATOR: Our next question comes from Meredith Magroite (ph) with Kaiser Daily HIV Reports. Please go ahead.
QUESTION: His. I was just wondering whether you had any opinion on treatment of partners, providers treatment of infected partners? I know that
California, for example, had proposed having its MediCal program pay for medications for sexual partners who providers did not see, but who--to
lower risk of reinfection they were going to dispense medications. I wonder if you had any opinions on that?
DR. BERMAN: Yes. This is Stuart Berman. The treatment of partners is critical to the treatment of chlamydia or gonorrhea that actually should be
seen as part of the management of the infected person. And there have been several approaches looking at how to facilitate treatment, and one of
the approaches that California has tried to go forward with is to facilitate treatment of partners by allowing the patients to provide--actually
doctors to give patients medication to give to their partners. There have been studies that suggested this has some benefit in reducing the
probability of reinfection. It certainly is no worse and it may be cheaper, more efficient, and there are things to be said for it. But the
critical part is that providers and other health care professionals need to do what they can to take responsibility for seeing that women or men
who are infected have their partners treated, and there's a series of things that they can do to make that work better.
QUESTION: Okay, thank you.
CDC MODERATOR: Next question.
AT&T MODERATOR: Our next question comes from Stu Wallace with A-18 News. Please go ahead.
QUESTION: Hi. I had a follow up on that. Since I'm writing for pediatricians, what do they do to make sure that their patients' partners are
getting treated when their own patients are under age?
DR. BERMAN: Well, you know, it depends on what you mean by under age. I mean--
QUESTION: Well, I mean that they're minors.
DR. BERMAN: Well, you know, the treatment--almost every state permits the treatment of STDs, quote, "among minors." And the age cutoff
varies, but that's sort of the statute in all of the 50 states. They have provisions to allow individuals to be treated without parental consent
for STDs, so that itself shouldn't be the challenge. There are a lot of clinical issues about how to manage that appropriately, how to deal with
it in a sensitive way, but that issue of minority shouldn't be the obstacle in and of itself to being treated.
QUESTION: Oh, no, I'm not talking about them directly, but like giving them for their partners to be treated in turn.
DR. BERMAN: Right. Well, this is a question of how they're notified, the responsibility of the individual adolescent to notify the partners, but
you have health departments that take on that responsibility of assisting with identification and treatment of partners who are exposed, and
therefore probably infected.
QUESTION: So in other words, you don't have anything special that you think pediatricians should be doing--
DR. BERMAN: Well, I think actually the important thing for pediatricians is that all too often pediatricians have not been really discussing or
advising or asking their patients about their sexual health. And if pediatricians were more proactive, asking about sexual behavior, inquiring
about the exposure to partners, screening and testing, and working with their health department, they would do a good deal more for their
patients. I think the issue is not so much that there are differences, but that they need to be proactive in addressing the sexual health issues
of their patients.
QUESTION: And if I could ask one other question. When you're talking about asking your patients about sexual orientation, it just seems like it
would be harder for pediatricians to do this too. You know, not normally do you have to talk to a kid about being sexually active, but then you
ask them if they're homosexual? Is there any way they can do it that's going to make it more--
DR. BERMAN: Well, let me see if other people have other comments, but there's no question that it's an incredibly challenging things for
pediatricians to do in the context of their office practice. And--but it's not impossible. Often it takes, you know, restructuring of their
office flow, additional training, but it is possible. But there are, as you have indicated, clear obstacles and that's the reason why a lot of
pediatricians don't do it. But the important thing is that you should be aware that one, that they--that there is a need for them to be
addressing it in terms of the percentage of their patients that are sexually active, and that they--a good many can do more, but it's going to
take some effort and training.
CDC MODERATOR: Next question, please.
AT&T MODERATOR: Our next question is a follow up from Christopher Heradia with the San Francisco Chronicle.
QUESTION: I was just wondering, is the first time you're recommending hepatitis-A and B vaccination for MSMs?
DR. WORKOWSKI: No, it is not. They were in our previous guidelines in the hepatitis-A and B sections of the 1998 treatment guidelines.
CDC MODERATOR: This is Cynthia. Let me make a clarification. The actual MSM section of the guidelines is new. Most of the screening that we have
recommended in this year's guidelines was actually done by risk factor previously and not--it wasn't set out as a different section.
QUESTION: Okay.
CDC MODERATOR: So let me clarify that. Sue was saying this was new. A lot of times we had it under "disease" or we had it under
"risk factors."
QUESTION: And I just wanted to confirm the spelling of Dr. Duerr's last name, D-u-e-r-r?
DR. DUERR: That's correct.
QUESTION: D-u-e-r-r. Okay, thank you.
CDC MODERATOR: Can we take some more questions, if anybody has any more questions, and let's take people that have not answered questions
before--or asked questions before
AT&T MODERATOR: We do have a question from Chris Flemming with Medicine Health.
QUESTION: [In progress] -- think is behind the increased resistance to cipro and other fluoroquinolones in California and whether it has
anything to do with either the use of cipro in perhaps cases where it was not needed after people reacted to the anthrax attacks, and also the
use in animals? Some people have said it gets overused, fluoroquinolones get over used in animals, and then create resistant bacteria in humans.
And also whether--how satisfied you are about the state and local capacity to track these diseases and bacteria-resistant incidences of these
diseases?
DR. WANG: Hi. This is Dr. Susan Wang. With regard to why this issue of fluoroquinolone resistance is now occurring in California, I think a key
issue is the proximity of California to Asia, to the Pacific region. Traditionally resistance in gonorrhea has pretty much emerged in Asia,
whether from penicillin or tetracycline and now with the fluoroquinolones, and then has gone from Asia to--then first seen in Hawaii in general
for the United States, and then subsequently on the West Coast. So I think that has been the major issue.
The use of fluoroquinolones for animals and in the human population for other infections is a concern, but it's probably somewhat less of a
concern for gonorrhea than it is for foodborne infections, and certainly--so I think that's less of an issue.
With regards to the public health response or the public health capacity to monitor resistance, I think we are becoming acutely aware that in
this day and age, in 2002, we don't have the extent of the surveillance going on that we did have in the 1980s when we changed our treatment
recommendations for penicillin and tetracycline. There are two reasons. One is technology has changed. Fewer and fewer places are actually doing
gonorrhea culture. Many sites are doing DNA-based testing, so that there--and we can only use culture, live organisms to test for
susceptibility.
But the other reason is that the capacity of local public health laboratories has not always been maintained. So fewer and fewer laboratories
are capable of doing culture and doing susceptibility testing than 15 years ago. So we do have a concern and I think this recommendation, the
new recommendation about treatment, is an alert across the country for public health departments that they need to maintain the capacity locally
and they do need to continue to monitor trends in resistance so that local treatment recommendations can be made appropriately.
CDC MODERATOR: Can we take the next question, please?
AT&T MODERATOR: If there are additional questions, you may press the 1 at this time. We do have a follow up question from Charlie Ohrenstein
with the LA Times.
QUESTION: I wanted to follow up about chlamydia partner treatment. Does the CDC support using Federal Medicaid funds to pay for partner
treatment?
DR. BERMAN: Well, I think we support partner treatment. Exactly how it's paid for I think is another agency's decision. But we think it's
critically important that partners get treated, and I think that to the extent that Medicaid could facilitate that treatment would be great.
CDC MODERATOR: Next question, follow up question?
AT&T MODERATOR: We have a final question from Tammy Smith with the Richmond Times Dispatch.
QUESTION: Hi, thanks for taking my call. A really quick question. Have there been any other states which have reported cases of cipro-resistant
gonorrhea?
DR. WANG: This is Dr. Wang again. We have had sporadic cases of ciprofloxacin-resistant gonorrhea reported from elsewhere in the United States,
so, yes, we have seen it.
QUESTION: Can you name those states or regions?
DR. WANG: We don't have all of the data yet for 2001, but we have seen it in Colorado, we've seen it in Utah. We've seen it in New York City.
And we've seen it in a few other places as well, but we're still finalizing our data for 2001.
QUESTION: Do you know Virginia, does that ring a bell, one of those states?
CDC MODERATOR: You can call 404-639-8895, we'll be able to help you with that.
QUESTION: Thank you.
CDC MODERATOR: Can we take any additional questions?
AT&T MODERATOR: We have no additional questions at this time.
